Doctors urged to be more mindful of costs of procedures they order

What if your hotel bill looked like a hospital bill, asks Vineet Arora, an assistant dean and associate professor of medicine at University of Chicago's Pritzker School of Medicine?

What if every guest received a different rate card, unneeded services were ordered and you were hit at the end with a huge bill that no one could explain?

"No one would ever go to a hotel like that," Arora said.

Yet every day, many patients enter the hospital without any idea how much their bill will be, and many doctors order tests and perform procedures oblivious to their cost.

Arora is part of small but growing movement of doctors and medical students who are trying to add "do no financial harm" to the Hippocratic oath taken by doctors and other medical personnel. She is creating a series of training videos for medical schools to help make students mindful not only of the cost to society of the care they will order but also of the cost to the patient.

"Our sector is eating into people's pocketbooks," said Andrew Levy, a recent medical school graduate who is working with Arora on the curriculum.

According to a 2005 Harvard study, medical bills are the No. 1 cause of bankruptcy in the U.S. Yet, of the $2.6 trillion spent each year on health costs, about 30 percent of that is not actually helping patients, and in some cases hurts them, said Steven Weinberger, CEO and executive vice president of the American College of Physicians. Doctors are responsible for a lot of that cost, which can be reduced without jeopardizing care, he said.

"We feel that it is our responsibility as physicians to be addressing this, because we have control over this. Not just the direct costs but also the finding of minor abnormalities that lead to a snowball effect, he said.

There is no other industry where the price for the exact same thing varies so widely, said Jeffrey Rice, CEO of Healthcare Blue Book, which compiles medical price data. For a patient paying out of pocket, a colonoscopy can cost from just under $1,000 to about $3,500, depending on the facility. If you add in the fact that each insurance company maintains dozens of different plans, the system is opaque to doctors as well as patients, he said.

"The lack of transparency about prices within the medical system is staggering," Weinberger said. "There is a cloud of secrecy over the whole system, and the patients who can least afford it often get the highest bills."

Levy said that if an uninsured or underinsured patient asks him what a medical bill would be, it's a question he does not know how to answer.

"We are totally insulated from price, what medical care actually costs the patient," he said. "I can't tell when a test I order becomes a bill or if and when my patient gets charged by it, and that's absurd."

Before Levy went to medical school, he suffered a torn cartilage in his knee. His doctor, he said, ordered an MRI, which would have cost Levy between $700 and $2,500 depending on the facility, since he had a $3,000 deductible on his health insurance. But he found out that he really didn't need the test after all, he said.

"This was nuts," Levy said, "to pay $700 out of my pocket for a test I didn't need. And I keep this in mind, that this is what my patients are going through."

Levy said the opacity of the system that insulates doctors from the cost side is not bad just for patients but for the medical field as a whole.

"We're in a service industry, one of the least consumer friendly," he said. "It sucks being in an industry where we can't help patients better."

Most doctors have little or no idea of how their decisions impact what people actually pay, and because of the complexity of system they have a hard time finding out, said Neel Shah, executive director of the not-for-profit Costs of Care and chief medical resident at Brigham & Women's Hospital in Boston.

Shah's organization, which commissioned Arora to create the medical school curriculum with a grant from the American Board of Internal Medicine, seeks to make the medical system more transparent. A major effort of the organization is to help doctors, who are often uncomfortable talking about money and the business side of medicine in general, understand their effect on the patient's wallet. He says the way the system works right now, to use a different metaphor, is like a restaurant menu with no prices, and people who order off of a menu with no prices always order steak.

"Not only are doctors not taught what things cost, but they traditionally have been taught not to think of it, as if thinking about costs somehow detracts from thinking about doing everything possible for the patient," Shah said.

When McKoy was in medical school more than 20 years ago, she said she was taught to go after the disease and get to the bottom of it, no matter what it took.

"We were trained to see the gallbladder, the back pain, the chest pain, not the patient," she said.

Because medical care is so expensive, and so many patientsare underinsured or insured but with high deductibles or copays, doctors have an ethical obligation to think broadly about their patients, including their costs, she said.

"I have a patient right now with a heart condition who won't take her medications because she can't afford it. She tells me, 'Doctor, I'm so worried about the cost,'" McKoy said. "Because I know this, I can think of alternatives."

McKoy believes that doctors must understand what their patients can afford; not to ration care but to find alternatives that patients, like her heart patient, can afford. This is so important to McKoy that when she taught a medical school class on the patient, physician and society, she would give her students an actual hospital bill and ask them to write a short essay about it.

"Patients need to know what they are getting into. They can lose their houses or their children's tuition money on medical care," said McKoy, who also has a law degree and a master's degree in business administration. "Patients have a right to know those things, and we don't tell you that."

By using evidenced-based research and avoiding a shotgun approach to testing, doctors can reduce medical costs without compromising care, Weinberger said. If a person is diagnosed with cancer and needs expensive chemotherapy, by all means he or sheshould get it, he said.

"But there is a lot of care that does not help patients, and in some cases actively harms them, and that we need to get rid of," Weinberger said.

Ira DuBrow, a pediatric cardiologist at Advocate Lutheran General Children's Hospital, believes that doctors should be ombudsmen for their patients and their pocketbooks. He can rattle off the cost of every medical test, procedure and drug he orders. He will tell anxious parents when an expensive test they ask for is no more effective than a cheaper one, and dispense with advanced and pricey diagnostic gadgetry altogether in favor of an old-fashioned hands-on examination, he says.

DuBrow also believes medical students should be taught early on to know what costs look like, as he put it, "on the other side of the stethoscope." Too many doctors are oblivious to the costs of care, and that is costing the country a lot of money without any corresponding benefit, he said.

"There are few things I'm dogmatic about, and I'm dogmatic about this: Someone is paying for this someplace," he said.

This spring, Brendan Bouffard, then a law student living in Oak Park, walked out of a local hospital emergency room, he said, after no one could tell how much a CT scan a doctor had ordered would cost. He went to the hospital with a migraine and bleeding in his left eye, after throwing up all night. The doctor who saw him seemed to be fairly certain that the bleeding was from a burst blood vessel in his eye, but ordered a CT scan on his brain to make sure, said Bouffard, now a lawyer in Williamston, Mich., who remains in good health.

Bouffard's health insurance required a 20 percent co-pay, and he asked a nurse about how much the CT scan would cost. She told him it could be between $2,000 and $10,000, he said.

"The doctor didn't seem to know either, and I told him that I couldn't risk getting a bill for $2,000 and not even knowing how much the total would be until the bill came in," said Bouffard.

The doctor told him to come back if he got worse, an answer that Bouffard didn't find completely satisfactory. Bouffard said he left without treatment.

Last year,Costs of Care sponsoreda popular essay contest that crowdsources hundreds of anecdotes from doctors, medical students and patients of how the system is failing patients. One of the finalists was cardiovascular surgeon Grayson WheatleyIII, from Phoenix. Wheatley described how despite his efforts to make sure that all the care for a surgical patient was in the man's insurance network, the anesthesiologist assigned by the hospital for the surgery was out of network, leaving the patient with a $6,000 bill.

"This could have been any hospital, any day in the U.S., and it probably happens more frequently than we know, because patients usually don't complain," said Wheatley. "I think there's a lot of silent sufferers out there put in financial jeopardy because of the current state of the medical system, who need to speak out."